Nuffield Health North Staffordshire Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patient who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. This key question has been rated good. This meant patient’s needs were met through good organisation and delivery.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patient and their communities.

The service had a clear vision for what it wanted to achieve and a strategy to turn it into action. This was visible within the hospital, and we observed a noticeboard in a staff area on Nuffield Health’s ‘Strategy to 2030’. This set out 5 key ambitions, to “Provide the best care and support you can get, anywhere, deliver the best possible customer and patient experience, be the best place you can work in health and wellbeing in the UK, be at least as efficient and productive as our competitors, and multiply our social impact and sustainability”. The service had clear objectives to meet the strategy, and leaders in the radiology service said they worked to disseminate the provider vision and strategy through emails, bimonthly staff meetings and well as in staff 1:1s and appraisals. We saw evidence that where a staff member fed back in a survey that they did not always understand the mission of the hospital, leaders acted by collecting patient good news stories to demonstrate outcomes and impact.

Staff were focused on the needs of patients receiving care, and leaders said staff were quick to offer suggestions to improve the service. The provider promoted equality and diversity with the implementation of dignity champions, staff members who promoted equality and dignity in their areas of work. There was not a dignity champion in the diagnostic imaging service at the time of inspection, however, all the staff we spoke with felt respected, supported and valued. The service provided opportunities for career development for those who wanted it. Success was recognised and celebrated in the service with staff of the month awards, ‘high 5’ awards and special mentions in staff huddles. We saw an award on display thanking a member of clerical staff for their work during an IT outage.

The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

The diagnostic imaging department was led by the radiology manager who was an experienced clinician and manager. They worked clinically as the breast lead and had recently completed a level 3 leadership and management apprenticeship. They ensured they were visible and approachable for staff, completing a walkaround each morning and operating an open office door policy. Staff spoke very highly of the radiology manager, stating they were supportive, personally and professionally, and particularly noted how well they led the service during a challenging time of IT outage last year. There was a deputy manager in post who had also been accepted onto a level 3 leadership and management apprenticeship. They were on maternity leave at the time of inspection, and the radiology manager was assisted by a clinical lead in their absence. The radiology manager said they also had a strong head of department peer group for support. The radiology manager reported to the director of clinical services, who reported to the hospital director. The hospital director described the "phenomenal" learning opportunities they and other leaders have had, including masters degree programmes. They held coffee mornings where staff were invited to engage and encouraged to speak up about anything concerning them.

Leaders at all levels understood the top risks in the service and mitigations in place. They used learning from incidents, as well as staff and patient feedback to improve the service.

The service fostered a generally positive culture where people knew they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas and all the staff we spoke with felt they would be able to raise any concerns without fear of detriment. There was a Freedom to Speak Up (FTSU) Guardian in the hospital who was highly visible on posters throughout the service, and whom staff could name. They had undergone the required training and had ringfenced time to perform the role. They spoke about previous work done around FTSU month, helping to prepare heads of department for the staff survey, and were preparing for this year’s FTSU month in October, including a presentation on psychological safety and a staff focus group. There were also 2 recently appointed FTSU champions, one of whom was a radiographer in the service, and another who was also a mental health first aider. There had not been any FTSU concerns raised by or about staff within diagnostic imaging, however, we heard about how other concerns had been actioned with staff and leaders, leading to resolution.

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

There was a provider equality, diversity and inclusion policy and staff were required to complete the equality, diversity and inclusion learning module annually. The service acted to prevent and address bullying and harassment at all levels and for all staff, and we did not hear about any examples of bullying, harassment or discrimination throughout the inspection. We heard examples of where staff with health conditions were offered reasonable adjustments including adjustments to workload and support from occupational health to support them to carry out their roles. Staff in diagnostic imaging scored inclusiveness 8.9 out of 10 on the latest staff survey

Staff had access to a pride network, Muslim network, neurodiversity network, women's network and social mobility working group. The hospital had held celebrations for events such as International Women's Day and Black History Month. Leaders told us that there was previously an LGBT+ champion in the hospital, they were not replaced when the previous champion left the provider, but dignity and equality champions encompassed this as part of their role. However, there was not a dignity champion in the radiology service.

The provider monitored gender pay gap, ethnicity pay gap and workforce demographics. At the time of the inspection 15.3% of the hospital workforce identified themselves as from a non-white background, with 9% of the local population from an ethnic minority group. Furthermore, 17.4% of leaders identified as being from a non-white ethnic background, indicating that ethnic minority representation within leadership exceeded the proportion represented across the wider workforce.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on information about risk, performance and outcomes, and shared this with others when appropriate.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them.

The service operated effective governance processes through local committees and on-site activities including quarterly radiology governance meetings, quarterly quality and safety committee and quarterly health and safety committee. We viewed minutes of relevant committees and saw there were clear agendas, and information was collected, monitored and communicated to attendees including members of the executive leadership. We saw escalations from smaller forums like the weekly adverse event forum into quality and safety committee. Performance data was analysed and compared within the provider organisation and where improvements were needed at the location level, action plans were developed to make this happen. We also viewed minutes from a cross-site mortality and morbidity meeting and saw learning from local cases was presented. A local annual radiation protection committee was held 6 weeks after the annual radiation protection advisor’s audit report as per provider policy, and actions from the most recent audit had been completed.

Risks were clearly identified and a formal register of these was used to keep oversight and manage mitigations and/or bring to resolution. The service had plans to cope with unexpected events including radiology down time procedures and major incident plans. The service had over 3 weeks of system down time in May 2025 which included the imaging archiving system and electronic patient appointment system. Leaders stated that procedures were effective and also credited robust administrative procedures including emailing all patients before their appointments to being able to operate during this time, as patient appointment details could be retrieved from emails.

There was a thorough process for approval of practicing privileges supported by an update to date policy. The process included provision of documents such as proof of identification, 2 references, latest appraisal, proof of medical indemnity insurance and General Medical Council (GMC) registration. Candidates underwent consideration of suitability by the medical advisory committee (MAC) and were interviewed by the hospital director before approval. The was a representative from radiology on MAC. We viewed the files of 3 radiologists and saw they contained evidence of up-to-date appraisals, enhanced disclosure and barring checks, medical indemnity insurance, GMC registration and Information Commissioner’s Office registration. The service reviewed practicing privileges every 2 years.

The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patient. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service such as the local integrated care board and partners from NHS services. Leaders and staff actively and openly engaged with patients and staff to plan and manage services. The radiology manager co-chaired the hospital patient experience forum. We viewed minutes and an action log from the January 2026 forum and saw that negative feedback regarding text messaging from the hospital had been highlighted for discussion with the senior leadership team.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contribute to safe, effective practice and research.

Staff and leaders were committed to continually learning and improving services. Leaders kept a log of quality improvement initiatives and saw that in the last year a new competency pack for radiology department assistants had been rolled out, and a new procedure for hydrogel injection of the knee introduced. The service set 3 ‘SMART’ objectives in February 2026 which included actively monitoring radiology call handling data to improve patient experience and operational efficiency. At the time of the inspection in July 2026, the service had the best call performance in the region. Managers had initiated a quality improvement project as there was no suitable MRI compatible equipment available to safely evacuate a patient who had collapsed or fallen to the floor within the MRI scanner room. An MRI safe evacuation mattress was procured as a result.

Leaders encouraged innovation and participation in research, and at the time of the inspection, the service was in discussion with a local trust regarding provision of spinal MRI for a rheumatology research project.

Nuffield Health North Staffordshire was awarded Hospital of the Year 2025 by the provider.